Before we really start thinking about ICD-10, we need to make sure that we are still familiar with our ICD-10 rules which are going to better prepare us for the implementation of ICD-10. Let’s talk about some documentation tips, including related medical coding guidelines from the ICD-9 book.
Updated books are mandatory and that may seem like a no-brainer but there are some practices that still do not purchase books every single year because they think that it's an unnecessary cost and that's not true.
One book is not going to cost you any more than the denial from using an outdated or invalid code. And that is true whether it's a diagnosis book or a procedure book. So having updated books are mandatory.
Your insurance companies are not required to use old books. Now, there are some exceptions and if you're from the state of California, then you will understand that your work comp carrier is on a much older book but that's an exception to the healthcare rule.
Now, supporting documentation is another story. You have to have supporting documentation for the codes that you are reporting to your carriers, whether it's the diagnosis or the procedure. And what - we'll talk about how important this is because we see an awful lot of presumption medical coding.
“Presumption” meaning, “Well, the patient's having an appendectomy. They must have appendicitis.” That does not support the documentation if the diagnosis code is blank.
Acronyms and abbreviations are often confusing. But they should be standard.
Different practices may have different requirements in that when you go to look at the diagnosis medical coding changes, most anesthesia practices are multispecialty in that we see all different sorts of surgery.
So we have to have our thinking cap on for all the different specialties as to what the changes are that will occur. But then other anesthesia practices may only deal with orthopedic cases so they only need to pay attention to the joint and bone, et cetera.
Or they may just be providing anesthesia for obstetrics and gynecology so there is a limited set of medical codes that are going to pertain to them, whereas other practices may just be pediatrics.
Everyone should already be familiar with these new abbreviations since we've had them for so long now. But AIPHI is your acute idiopathic pulmonary hemmorhage in infants, all of these are new terms that are referenced when your coding book comes out. BMI goes back always for most coders who do recognize that as body mass index
You must use the standards ones or know what it is that they're trying to convey by way of diagnosis information.
Make a list of the acronyms your practice uses
There are some that are not listed in the known and acceptable acronyms and you may find that often there are some that pertain to more than one.
So if you are using a number or a large number of acronyms in your practice, sit down and make yourself the list so you know what they are and you know that it's shared with the people that are both writing these diagnosis codes down and billing them. If you have a billing service, they should also have a copy of the list.
You will want to update your list of standard abbreviations at least once a year or just look at it to see if it needs any changes or more often if necessary. Our expert suggested in a medical coding conference that if you have a new practitioner coming in who has their own acronyms, then you may need to update more than once a year.
One of the recommendations with these coding updates is that you at least list a revision date at the bottom so that everyone knows what the most up-to-date list is and when one supersedes another.
There are often confusing acronyms. Here's one of them. Sometimes you have to look to the actual procedure itself to understand what the clinical provider is trying to tell you. Was FTP a full-term pregnancy? Probably not if it was a C-section. If it was a C-section, it was probably failure to progress.
Here's another one, TKA. Now, most coders do recognize that TKA is a known acronym for a total knee arthroplasty. But we have seen mistakes where it was misinterpreted as a total knee arthroscopy. And there are different base values associated with that.
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